Patient Text Message Consent Form

Name

First NameLast Name

Date of birth

Date

Phone Number

Please enter a valid phone number.

I agree to be contacted by Your Infinity Health via SMS text messaging. YIH will not share my consent or phone numbers with any unauthorized third party. Examples of messages I might receive could include appointment reminders, service announcements, or general health education and awareness tips. These messages may contain information such as patient’s name, appointment date, location, and provider name. Messages will never include actual lab or test results or diagnosis information. I understand that standard text messaging and data rates may apply under my cell phone service agreement but that Your Infinity Health will not charge a fee for this service. Message frequency is dependent on patient activity. Should I change my mobile phone number, I understand I am responsible for notifying Your Infinity Health of the change and for providing a new cell phone number if I wish for the service to continue. I acknowledge that opting out of receiving SMS messages may impact my experience with any service(s) that relies on communications via SMS messaging.

If you no longer wish to receive text messages, reply “STOP at any time, or call 1-833-900-1741-101. For more information
text “HELP” or call 1-833-900-1741-101. Data and Message rates may apply.

I hereby give my consent to receive text messages from YIH (as per the above number).